SERVICES In-Network You Pay

AnnuAl DeDuctible6

Individual None

Individual & Child(ren) None

Individual & Adult None

Family None

AnnuAl Out-Of-POcket limit6

Individual $3,300

Individual & Child(ren) $6,400

Individual & Adult $7,700

Family $10,100

lifetime mAximum Unlimited

Preventive ServiceS

Well-Child Care

0-24 months $10 per visit

24 months-13 years (immunization visit) $10 per visit

24 months-13 years (non-immunization visit) $20 per visit

14-17 years $20 per visit

Adult Physical Examination $20 PCP/$30 Specialist per visit

Routine GYN Visits $20 per visit

Mammograms No charge2

Cancer Screening (Pap Test, Prostate and Colorectal)

No charge2

Office viSitS, lAbS & teSting

Office Visits for Illness $20 PCP/$30 Specialist per visit

Diagnostic Services No charge2

X-ray and Lab Tests No charge2

Allergy Testing7 $20 PCP/$30 Specialist per visit

Allergy Shots7 $20 PCP/$30 Specialist per visit

Outpatient Physical, Speech and Occupational Therapy5 (limited to 30 visits/condition/benefit period)

$30 per visit

Outpatient Chiropractic5,9 (limited to 20 visits/condition/benefit period)

$30 per visit

emergency cAre AnD urgent cAre

Physician's Office $20 PCP/$30 Specialist per visit

Urgent Care Center $30 per visit

Hospital Emergency Room5 $35 per visit (waived if admitted)

Ambulance (if medically necessary) No charge2

HOSPitAlizAtiOn8

Inpatient Facility Services No charge2

Outpatient Facility Services $30 per visit

Inpatient Physician Services No charge2

Outpatient Physician Services $30 per visit

BlueChoice HMO Summary of Benefits

Maryland Small Group Reform

SERVICES In-Network You Pay

HOSPitAl AlternAtiveS8

Home Health Care No charge2

Hospice No charge2

Skilled Nursing Facility (limited to 100 days/year)5 No charge2

mAternity

Prenatal and Postnatal Office Visits $20 per visit

Delivery and Facility Services8 No charge2

Nursery Care of Newborn3 No charge2

Initial Office Consultation(s) for Infertility Services/Procedures $30 Specialist per visit

Artificial Insemination1 50% of the Allowed Benefit (after diagnosis is confirmed)

In Vitro Fertilization Procedures1 Not covered

mentAl HeAltH (mH) AnD SubStAnce AbuSe (SA)8

Inpatient Facility Services(limited to 60 days/benefit period)

No charge2

Inpatient Physician Services No charge2

Outpatient Services (MH & SA) 30% of the Allowed Benefit

Partial Hospitalization5

(each day counts as 1/2 day toward inpatient limit)No charge2

Medication Management Visit $20 PCP/$30 Specialist per visit

miScellAneOuS

Durable Medical Equipment8 No charge2

Acupuncture Not covered, unless mediclaly necessary Plan approved for anesthesia and when services are rendered in conjunction with Physical Therapy

Transplants8 Covered as stated in Evidence of Coverage

Hearing Aids for ages 0-18 (limited to $1,400 max per hearing aid every 3 years)5

No charge2

viSiOn

Routine Exam (optometrist or ophthalmologist)(limited to 1 visit/benefit period)

$10 per visit at participating Vision Centers

Eyeglasses and Contact Lenses Discounts from participating Vision Centers

CUT5567-1P (5/07)Medical Option 2CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association.

® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

1 Members who are unable to conceive have coverage for the evaluation of infertility services performed to confirm an infertility diagnosis, and some treatment option for infertility. However, assisted reproduction (AI) services performed as treatment option for infertility are only available under the terms of the members contract. Preauthorization required.

2 No copayments or coinsurance.3 Newborns must be enrolled within 31 days of birth.4 Emergency room copay applies to the deductible.5 CareFirst BlueChoice may be providing your BlueChoice benefits on either a contract or calendar year basis. Please refer to your benefits

contract to determine which method applies to your group benefit plan.6 Please refer to your Evidence of Coverage to determine your coverage level.7 If office copayment has been paid additional office copayment not required for this service.8 Preauthorization required.9 Consultation for chiropractic services is charged the same as office visit for illness.

Note: Note: Upon enrollment in CareFirst BlueChoice, you will need to select a Primary Care Physician (PCP). To select a PCP, go to www.carefirst.com for the most current listing of PCPs from our online provider directory. You may also call the Member Services toll free phone number on the front of your CareFirst BlueChoice ID card for assistance in selecting a PCP or obtaining a printed copy of the CareFirst BlueChoice provider directory.

Not all services and procedures are covered by your benefits contract. This plan summary is for comparison purposes only and does not create rights not given through the benefit plan.

Policy Form Numbers: MD/CFBC/MSGR/GC (2/07) • MD/CFBC/MSGR/EOC (7/06) • MD/CFBC/MSGR/SOB/ENHANCE (7/06) • GS-CC (MSGR) REV (9/05) • MD/BC-OOP/VISION (R. 6/04) • MD/CFBC/MSGR/SOB/CORE (7/06) • MD/CFBC/MSGR/DOCS (2/07) and any amendments.

www.carefirst.com

$0 Deductible$10/20/30 Retail CopaysUPGRADE II

The Three Tier Prescription Drug Program

This prescription drug program is offered as part of your health care benefits. This program covers both non-maintenance and maintenance prescription drugs dispensed by a retail pharmacy or designated mail service pharmacy.

This program is based on the CareFirst BlueChoice, Inc. (CareFirst BlueChoice) preferred drug list, which is made up of certain brand name prescription drugs (Tier 2) and all generic prescription drugs (Tier 1). Your participating physician has a complete copy of the CareFirst BlueChoice preferred drug list. A copy can also be found at www.carefirst.com/rx.

How Do I Use My Benefit?

Talk to your doctor when you are prescribed medications to see if you are using drugs that are on the preferred drug list – these are also known as Tier 1 or Tier 2 drugs. You will save the most money if you can take those medications. You can also see if medications you are currently taking are on the preferred drug list by visiting the prescription drug site at www.carefirst.com/rx. You can get your prescription filled by using the retail or mail order programs.

Did You Know?

n If the cost of your medication is less than your copayment, you pay the cost of the medication.

n A generic drug is a prescription drug that by law must have the equivalent chemical composition as a specific brand name prescription drug.

n You can use your prescription drug card at more than 59,000 participating pharmacies nationwide.

n Frequently asked questions about your prescription benefits are available at www.carefirst.com/rx.

Access www.carefirst.com/rx for more informAtion About the 3-tier PrescriPtion Drug ProgrAm

AnD for the most uP-to-DAte PreferreD Drug list.

Retail ProgramThe retail program provides up to a 34-day supply of medication. Simply present your prescription drug identification card at one of more than 59,000 participating pharmacies nationwide and pay the appropriate copayment for your medication.

Generic Drug (Tier 1) $10

Preferred Brand Name Drug (Tier 2) $20

*Non-Preferred Brand Name Drug (Tier 3) $30

Mail Order ProgramThe mail service program is a convenient way for you to order medications. Your prescription is reviewed and dispensed by registered pharmacists and mailed directly to your home. Call Walgreens Mail Service at (800) 745-6285 for more information.

34-day supply 1 Copay

35 to 90-day supply (maintenance only) 2 Copays

Maintenance DrugsUp to a 90-day supply of maintenance drugs are available through the retail or mail order pharmacy. Maintenance medication is a prescription drug anticipated to be required for 6 months or more to treat a chronic condition.

Generic Drug (Tier 1) $20

Preferred Brand Name Drug (Tier 2) $40

*Non-Preferred Brand Name Drug (Tier 3) $60

* Non-preferred brand name drugs are not part of the preferred drug list but are covered at the highest copay.

Maryland Small Group Reform

Prescription Drug Program

Plan Feature Amount Description

Deductible None Your benefit does not have a deductible.

Generic Drugs (Tier 1) $10 All generic drugs are covered at this copay level.

(up to a 34-day supply)

Preferred Brand Name Drugs (Tier 2) $20 All preferred brand name drugs are covered at this copay level.

(up to a 34-day supply)

Non-Preferred Brand Name Drugs (Tier 3) $30 All non-preferred brand name drugs are covered at this

(up to a 34-day supply) copay level. These drugs are not on the preferred drug list.

Check the online preferred drug list to see if there is an

alternative drug available. Discuss using alternatives with

your physician or pharmacist.

Annual Maximum N/A Your benefit does not have an annual benefit maximum.

Maintenance Copays generic: $20 Maintenance drugs of up to a 90-day supply are available for

(up to a 90-day supply) preferred: $40 twice your copay through the mail service or retail pharmacy.

non-preferred: $60

Generic Substitution Yes If you choose a non-preferred brand name drug (Tier 3) over its

generic equivalent (Tier 1), you will pay the highest copay PLUS

the difference in cost between the non-preferred brand name

drug and the generic drug up to the cost of the prescription.

Prior Authorization Yes Some prescription drugs require Prior Authorization. Prior

Authorization is a tool used to ensure that you will achieve

the maximum clinical benefit from the use of specific targeted

drugs. Your physician or pharmacist must call to begin the

prior authorization process. For the most up-to-date prior

authorization list, visit the prescription drug web site at

www.carefirst.com/rx.

CUT5708-1P (10/07)

Benefits Summary

The preferred drug list changes frequently in response to Food and Drug Administration (FDA) requirements. The list is also adjusted when a generic drug is introduced for a brand name drug. When that happens, the generic drug will be added to the Tier 1 list and the brand name drug will move from Tier 2 to Tier 3. For the most recent information about the preferred drug list, visit the prescription drug web site at www.carefirst.com/rx.

Need More Information?

On the Phone… If you have questions about your prescription drug coverage or the preferred drug list, call Argus Health Systems at (800) 241-3371.

You should contact your physician or pharmacist if you have questions regarding the type of drug, side effects, drug interactions, storage, etc.

By Mail… If you have questions about your Mail Order benefits, call Walgreens Mail Service at (800) 745-6285.

On the Web… For the most recent information regarding the 3-tier prescription drug program, changes to the preferred drug list, etc. visit the prescription drug web site at www.carefirst.com/rx.

This plan summary is for comparison purposes only and does not create rights not given through the benefit plan.Policy Form Numbers: MD/CFBC/MSGR/RX (7/06)

CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.